Legal and regulatory proceedings
House calls: What the courts have said
An article for physicians by physicians
Originally published Spring 1995 / Revised February 2008
House calls place the doctor in an unfamiliar situation where it may be more difficult to obtain a history or to perform a physical examination.
Of interest to physicians who may see patients in unfamiliar circumstances
In a house call, although the setting in which the doctor-patient relationship takes place is informal, the duty of care imposed on the physician is as stringent as in the formal environment of the physician's office or the hospital. The following case illustrates the need to obtain a history and perform a physical examination as thoroughly in the patient's home as in the office.
Mrs S.B. presented herself to the emergency department of a regional hospital on a Sunday at 2335h. She was seen by the emergentologist shortly thereafter and gave the following history: she was 66 years old and had had severe epigastric pain for the past two hours. She had no previous history of heart disease and was on an oral hypoglycemic medication. She acknowledged having been drinking large amounts of alcohol in the last few days. Her temperature was 35°, pulse 104, respirations 24, blood pressure 130/70. Examination revealed an obese woman, chest was clear, heart sounds were normal. The abdomen was soft and tender in the epigastric region. There was no guarding, no rebound. The emergentologist suspected alcohol gastritis and requested a surgical consultation.
She was seen by the surgeon ten minutes later. She told him that in fact, she had had the pain all day and she had taken a substantial amount of ice chips p.o. but the pain had become severe only two or three hours before, after eating some scalloped potatoes and onions. The pain was situated mainly in the epigastric region. There was no back pain. She denied any previous history of epigastric pain although she had had periods of indigestion from time to time. She was nauseated but had not had any vomiting. Her bowel movements had been regular and she had no history of bleeding. On examination, there was no rebound tenderness, bowel sounds were normal. She had one small emesis during the examination. The surgeon concurred with the diagnosis and suggested narcotic analgesia, antiemetic and an antispasmodic as well as antacid and H2 blocker if necessary and a bland diet. He advised the emergentologist to admit her if the symptoms did not improve.
The pain settled down with that treatment. She was reassessed by the emergentologist after an hour and she was discharged home. She was told to return to the emergency department if the pain returned.
The next day, her family physician was called. As he was not available, his associate went to see her at home around 1230h. When he entered the home, he found the patient fully dressed in street clothes, sitting in the living room. She appeared to be in some discomfort but not in great distress. Her colour was good and there was no diaphoresis. She related the events of the night before and her husband indicated that since returning home, she had continued to have abdominal pain and had vomited twice but with no blood in the vomitus. She had continued to drink and sip alcohol to ease the pain. On examination, there was a strong smell of alcohol; however, her speech was clear. She did not seem to be intoxicated. She localized the pain to her epigastric region. On examination the doctor noted a obese abdomen. He palpated the four quadrants of the abdomen through a thin blouse while the patient was reclining backward and found no rigidity or rebound tenderness, but did find some voluntary guarding in the epigastric region. He concluded she had acute alcohol gastritis and gave her an injection of narcotic. He advised her to stop drinking and to call back or return to the hospital if the pain did not settle in a couple of hours.
Around 2130h that day, the patient suddenly collapsed at home. She was rushed to the hospital but could not be resuscitated. An autopsy showed a 2 cm wide perforated anterior duodenal ulcer and peritonitis. There was also severe liver cirrhosis. Litigation was started one year later against the hospital, the emergentologist, the surgeon and the family physician who had seen her at home.
Review of the records at that time indicated that a duodenal ulcer had been diagnosed six years previously, however, it had resolved after one month and she had had no further complaint.
The plaintiff's expert was not critical of the emergentologist or the surgeon, and they were released from the legal action. However, criticism was directed towards the work of the general practitioner. In response the Association's lawyer sought the opinion of another doctor with a similar practice. That expert criticized both the incomplete history (no information elicited regarding the previous ulcer) and the cursory physical examination (patient was not undressed, and was not lying flat). The involved doctor became increasingly critical of himself. The case therefore could not be defended and a settlement was made with the family by CMPA on behalf of the general practitioner.
This case illustrates some of the possible challenges related to the provision of care in an unfamiliar setting.